Abstract:

Introduction:
Exclusive breastfeeding (EBF) is established as the safest feeding method in
the first half of infancy. Mixing breast milk and other foods, including nonhuman
milk and semi-solid foods (MF), before 6 months carries an increased
risk of child mortality compared to EBF due to infectious diseases.
Replacement feeding (RF) is only recommended for HIV-1 positive mothers
when it is acceptable, feasible, affordable, sustainable and safe (AFASS). This
thesis assesses infant feeding practices, growth and related factors in Mbale,
Eastern Uganda, where infant mortality rate is ~80/1000 and adult HIV-1
prevalence is 5-6 %.
Methods:
The thesis comprises: 1) a cross-sectional survey of 727 mother-infant pairs
(paper I and II); 2) a follow-up study of 30 mother-infant pairs seen weekly for
12 weeks after birth (paper III); and 3) 8 focus group discussions, 4 among
men and 4 among women (paper IV). From the cross-sectional survey, infant
feeding practices - according to dietary recall since birth and the 24-hour
dietary recall - were assessed in addition to early infant feeding practices and
associated factors. Infant anthropometric status, including determinants for
undernutrition, is presented in relation to feeding practices and sociodemographic
characteristics. From the follow-up study, feeding modalities
yielded from weekly assessments were compared to those obtained from the
dietary recall since birth, being conducted at weeks 6 and 12 post-partum using
Kaplan-Meier analysis. Perceptions of both fathers and mothers regarding
infant feeding practices have been addressed in the focus group discussions,
and inductive content analysis was used. This thesis combines the quantitative
and qualitative studies under the ‘mixed methods approach.’
Results:
The main finding was that despite universal breastfeeding EBF was scarcely
practiced. Dietary recall from the survey showed that 7% and 0% practiced
EBF at 3 and 6 months, respectively. The feeding modalities obtained from the
24-hour recall versus recall since birth showed discrepancies. The EBF
prevalence was much higher according to the 24-hour recall than the recall
since birth. Pre-lacteal feeds were given to 57% of the infants in the survey,
and it was widely accepted according to the qualitative findings. Breast milk
was often perceived as ‘not enough’ from birth. In the survey half of the
mothers had not initiated breastfeeding within two hours, and still after the first day a quarter had not initiated it. Initiation of breastfeeding was delayed for a
variety of reasons; the qualitative findings emphasized hygiene procedures and
traditions. Insufficient supplementary feeding occurred in the second half of
infancy.
S tunting increased with age: of the infants in the survey alone, 17% were
stunted. Fewer girls than boys were stunted (41% versus 59%, OR 0.6 95% CI
0.4 – 0.97). Low wealth status was associated with decrease in linear growth as
well as sub-optimal infant feeding practices.
The feeding modalities obtained from the prospective weekly follow-up
showed a similar pattern as the results obtained from the recall since birth at 3
months, but estimates from the recall since birth were slightly longer (~1
week). At 12 weeks post-partum, the mean duration for ending EBF and
starting predominant breastfeeding (PBF), by introducing water liquids and
fruit juices, was 0.5 weeks (95% CI 0-1.1 weeks) according to the frequent
short-time recalls, and 1.4 weeks (95% CI 0.1-2.7 weeks) for the recall since
birth (Mantel-Cox-test, p=0.15). The mean time for ending PBF and starting
MF was 5.2 weeks (95% CI 3.9 – 6.5 weeks) according to the frequent shorttime
recalls, and 6.6 weeks (95% CI 5.4-7.8 weeks) for the recall since birth
(Mantel-Cox-test, p=0.20).
Even if the health system conveyed the concept of ‘exclusive breastfeeding’,
mothers did not seem to have an ‘internalised knowledge’ of it and why it was
promoted. An illustrative quote from the discussions among mothers was: ‘I
want to know why they refuse us to give other feeds during the first six
months.’ Men felt left out of the children’s health education, and said they had
learnt ‘nothing.’ Not undertaking breastfeeding was seen as unacceptable in
the qualitative study, except for maternal illness, and it was socially
sanctioned. Verbal accusation, physical violence and even divorce could be the
result of a non-breastfeeding decision according to the qualitative analysis.
Conclusion:
Sub-optimal feeding practices and high stunting rates were seen. Dietary recall
since birth provides an informative tool for recording infant feeding
modalities. Poverty was strongly associated with impaired growth and suboptimal
infant feeding practices, and parents expressed confusion and
difficulties adhering to the recommended feeding practices. Hindrances
experienced by the mothers to practice recommended infant feeding practices,
including EBF, need to be taken into consideration, and the involvement of
fathers is imperative.